Antenatal Care Strengthening in Jimma, Ethiopia: A

Mixed-Method Needs Assessment

Abstract
Objective. We assessed how health system priorities matched user
expectations

and

what

the

needs

for

antenatal

care

(ANC)

strengthening were for improved maternal health in Jimma, Ethiopia.

Methods. A questionnaire survey among all recent mothers in the study
area was conducted to study the content of ANC and to identify the
predictors of low ANC satisfaction. Further, a qualitative approach was
applied to understand perceptions, practices, and policies of ANC.
Results. There were no national guidelines for ANC in Ethiopia. Within
the health system, the teaching of health professional students was
given high priority, and that contributed to a lack of continuity and
privacy. To the women, poor user-provider interaction was a serious
concern hindering the trust in the health care providers. Further, the
care provision was compromised by the inadequate laboratory
facilities, unstructured health education, and lack of training of health
professionals. Conclusions. Health system trials are needed to study
the feasibility of ANC strengthening in the study area. Nationally and
internationally,

the

leadership

needs

to

be

strengthened

with

supportive supervision geared towards building trust and mutual

respect to protect maternal and infant health.

1. Introduction
We approach the countdown for the MDG5 for improved maternal
health [1], and how to deliver quality antenatal care (ANC) in low-

income countries becomes an important issue to address. With the

MDGs, maternal health has received increasing political attention;
however, little attention has been given to ANC, even though the
guidelines for Focused ANC (FANC) were launched concurrently [2]. The
risk of maternal death is by and large not predictable during
pregnancy, and it is argued that ANC has limited effects on maternal
death [3, 4]. The most important strategy for reduced maternal
mortality is to ensure that women give birth by skilled attendance [5
7]. Consequently, there is an ongoing debate about the importance of
ANC

for

maternal

health.

Nevertheless,

pregnant

women

are

embracing the idea of care during pregnancy; in sub-Saharan Africa,

three in four pregnant women receive at least one ANC visit [1].
Generally, guidelines for FANC have not been fully implemented in lowincome settings [8], and the quality of ANC is often low [912]. The
ANC is increasingly focused on and acknowledged for providing health
education, instructions on danger signs during pregnancy, and birth
preparedness, as this is considered to be lifesaving and to reduce delay
in seeking help [8]. The opportunities of the ANC program to counsel
women in the need for skilled birth attendance have not been
sufficiently investigated [13]. Thus, while the importance of a highly
utilized health program is under debate, the priority of the area (hence
the quality of the actual care provided) is low, and research on how to
strengthen the ANC is needed.
In Ethiopia, maternal mortality rates have been among the highest in
the world, although currently there are indications of a marked decline
[14]. According to estimates, the maternal mortality ratio was 990 per
100,000 live births in 1990 [15] but was estimated to 676 in 2010 [16].
At national level, most recent data show that only 10% give birth under

the care of a skilled provider, 51% in urban and 4% in rural settings

[17]. From 2005 to 2011, the proportion attending ANC increased from
28 to 34%. Urban women were twice as likely to attend ANC as rural
women were. Local studies characterise the ANC service by unclear
guidelines, lack of training of providers [18, 19], and poor health
system registration, but the Preventing Mother-to-Child Transmission
(PMTCT) program seems to receive higher priority than the ANC
program [20]. It has not been possible to identify documents providing
an Ethiopian schedule for ANC. One study mentions that in 2005 FANC
was not implemented [19], but in other studies [16, 18, 20] coverage
of four visits is reported. FANC guidelines suggest that four visits per
pregnancy will suffice, if the woman does not experience complications
[2]. How ANC services are prioritised by the Ethiopian health
authorities might be reflected in The National Reproductive Health
Strategy 20062015 [21]. Overall, ANC is not central to the document,
and the priority areas are social and cultural determinants of womens
health, fertility and family planning, maternal and newborn health,
HIV/AIDS, reproductive health of young people, and reproductive organ
cancers. Thus, Ethiopia seems a relevant case for the study of how to
strengthen the implementation of quality ANC for improved maternal
health.
The aims of this study were to analyse if the health system priorities
matched the user expectation and to assess the needs for ANC
strengthening for improved maternal health in the Jimma area of
Ethiopia. The specific objectives of the quantitative component were to
analyse the content of ANC and to identify the predictors of low ANC
satisfaction, while the specific objectives of the qualitative component
were to understand perceptions, practices, and policies of ANC.

2. Materials and Methods

2.1. Study Design
The

study

was

needs

assessment

aimed

at

informing

the

development of a complex intervention study that would test the

feasibility of ANC strengthening in Ethiopia. We applied the WHO
guidelines for FANC as the best practice for efficient care, and the
present paper provides an in-depth understanding that can guide
adaption of FANC to the Jimma context. Using the terminology from the
British

Medical

Research

Council

(MRC)

guidance

on

complex

interventions, this needs assessment is contributing to the initial

phases of trial development, where the program theory is developed
and modelled [22]. Implementation of policies for reduction of
maternal mortality without involvement of local stakeholders and
contextual understanding has previously been found to be ineffective
[23]. Our choice of conducting an in-depth analysis of ANC in the local
setting is in line with the theories for the planning of health promotion
programs, where need for user-involvement and application of
qualitative research is highlighted [24, 25].
2.2. Setting
The study was conducted in Jimma city, which has a population of
121,000, and in the surrounding urban communities of Serbo and
Agaro. The ANC program of all public health facilities in the area was
studied, four health centres (Jimma Town, Higher 2, Serbo, and Agaro)
and one hospital (Jimma University Specialized Hospital). The hospital
serves as a referral site and provides specialized care for southwestern
Ethiopia, with a catchment population of about 15 million, and ANC
service

is

provided

for

women

with

complicated

as

well

as

uncomplicated pregnancies. At the health centres, pregnant women

from the nearby urban and rural communities are seen, and primary
health care services (including ANC, delivery services, postpartum
care, and family planning) to all population groups are provided. The
registration system is poor, but an estimated 6,500 pregnant women
are seen at the facilities per year. All facilities are training sites for all
types of health care professionals.
2.3. Data Collection
Field work was conducted in the study area from August 2008 to
August 2009 by SFV, with linguistic, cultural, and logistical support
from AT.
The quantitative component was a questionnaire survey at the
household level. All women residing in the study area who gave birth in
the year preceding the interview (date of birth from April 28, 2008, to
June 20, 2009) were invited to participate. We collected information
about the use of and experience with health facilities during the last
pregnancy, and women were asked to recall the content of care
received during ANC. The questions were based on the components of
care recommended in the WHO FANC model and were inspired by the
Ethiopian

Demographic

Health

Survey

[26].

The

questions

on

laboratory testing were divided into (1) urine analysis, (2) HIV test, and
(3) other blood analyses (haemoglobin, blood group, Rh status, and
syphilis test). The women were asked to rate how much they were
satisfied with the service received during last pregnancy. User
satisfaction was originally coded as follows: very satisfied, acceptable,
and not satisfied, but for the regression model very satisfied and
acceptable were merged. The questionnaire was in Amharic and the

translation was conducted by a group of local nurses and corrected by

DN and AGM independently, and the questionnaire was pilot tested.
Data were collected by 23 trained female data collectors. Local guides
from the kebeles (smallest administrative unit) helped to identify
eligible women by walking from door to door. Data were double
entered by trained data entry clerks.
The qualitative component included observations at ANC facilities, indepth interviews with recent mothers and health system leaders, focus
group

discussions

(male

spouses

and

TBAs

(Traditional

Birth

Attendants)), and workshops with health professionals. Observations

took place regularly at all ANC facilities, adding up to 2040 hours per
site, and were focused on the infrastructure, availability of technology,
types of health staff, and interaction between user and provider.
Extensive field notes were taken based on these observations.
In-depth interviews were conducted with 13 recent mothers (20 days
to 5 months after delivery) to understand their perceptions and
experiences regarding pregnancy and utilization of ANC. We used
purposeful sampling to capture the variation in ANC service delivered
at different levels of care, women who followed ANC at hospital (3) or
health centre level (6) or did not have any ANC at all (4). The ANC
attendants were selected from the ANC archive and nonattendants
from the archive of childhood immunizations. The tracing of women
was difficult and time consuming due to incomplete registration at
facility level and an informal address structure in the community. Apart
from level of care, the sampling was therefore based on convenience.
The women were interviewed in their own households by SFV and AT.
Interview guidelines were developed in the local setting together with
health professionals, pilot tested, and translated into the local

language. The interviews were semistructured and took 25 to 45

minutes.
A focus group discussion with eight male spouses visiting Jimma Town
Health

Centre

perceptions

was

of

conducted

pregnancy

and

to

gain

to

information

understand

about their

decision-making

processes at the family level. These men attended the facility for
different purposes on the day of the focus group. Further, a focus group
discussion with 12 TBAs, who were recruited through a local
nongovernmental organization (Family Guidance Association), was
conducted to explore their roles regarding pregnancy and delivery at
the community level. The discussions were conducted in the local
language and facilitated by AGM. All interviews and discussions were
recorded and later transcribed and translated into English.
Workshops with clinical staff members were conducted at Serbo, Jimma
Town, and Higher 2 Health Centre and at the hospital (no physicians
participated). The workshops consisted of two hours of group-based
discussions on strengths, weaknesses, and solutions in ANC provision.
The

groups

subsequently

presented

posters

with

their

main

perspectives for the rest of the group. Key informant interviews were
performed with health authorities from the Town Health Bureau and
managers from the obstetric department at the hospital in order to
understand their perceptions of the organisation of the service as well
as the regional and national priorities.
2.4. Data Analysis
The survey data were analysed using mixed effect logistic regression to
identify predictors of being dissatisfied with the service. Health facility
was analysed as the random effect parameter to adjust for the

potential clustering of women using each health facility. Further

adjustment was made for maternal age, socioeconomic status, and
number of ANC visits. All analyses were performed in STATA 11.0
(StatCorp, Texas, USA).
The initial analysis of the qualitative interview data and focus group
discussions was based on domain analysis [27]. Data were organised
into categories reflecting the topics which the participants gave
importance to. The categories were grouped in more superior domains,
and patterns and relations between these were explored. The latter
part of the analysis was inspired by hermeneutic perspectives [28].
Posters from the workshops with health professionals were analysed,
and the context of the workshops and the interpersonal dynamics
among the health professionals were kept in mind. Perspectives
evolving from the field observations were discussed with colleagues
and local health professionals for validation and contextualisation.
The quantitative and qualitative analyses were carried out with a
parallel approach [29]. This indicates that the research questions of the
two approaches were not initially integrated and the two approaches
were designed to apply with the standards of the two disciplines
separately. In the discussion of this study, however, the qualitative and
quantitative findings were triangulated and the conclusions on the
research

question

were

based

on

whether

the

findings

were

converging, diverging, or complementary [29].

2.5. Ethics
Ethical permission was obtained from the Jimma University Ethical
Review Committee of the College of Public Health and Medical
Sciences, and permission to observe the practice at health facilities

was obtained from the relevant town and zonal health bureaus as well
as the hospital administration. All informants were ensured anonymity
and confidentiality, and they gave their informed consent after
appropriate explanation of the study objectives and content.

3. Results
3.1. Quantitative Results
Of 1392 eligible women, 1364 (98%) consented to participate. The
mean (range) age was 24.5 (1546) years (Table 1). The majority lived
in Jimma (72%) and were cohabitating (92%). Almost 20% had never
been to school and 42% were primiparous. During the previous
pregnancy, 83% attended ANC and 67% gave birth in a health
institution.
Table 1: Background characteristics of 1364 women who had given birth within the previous 12
months in the Jimma area1.
Age, years, mean SD ()
Place of residence
Jimma
Serbo
Agaro
Maternal education
No school
Primary school
Secondary or higher school
Marital status
Single
Widow/divorced
Cohabitating
Parity
Para I
Para II
Para III
Para IV+
Outcome of last pregnancy
Singletons

24.5 4.7 (1357)

71.6 (974)
6.3 (86)
22.1 (301)

19.9 (271)
46.1 (628)
34.0 (464)

2.8 (38)
5.1 (69)
92.1 (1254)

42.0 (566)
26.4 (355)
14.9 (201)
16.7 (225)

98.0 (1336)

Twins and triplets

2.1 (28)
ANC attendance during last pregnancy

Yes
83.1 (1132)
No
17.0 (231)
Place of delivery

Health facility
67.4 (904)
Home
32.6 (437)
All numbers are % () unless otherwise indicated. Numbers do not add up due to missing data.

Almost 60% attended their 1st visit in the 2nd trimester (Table 2). Few
women had only one visit (3%); 25% had four, whereas 44% had more
than four visits. Measurements of blood pressure, weight, Tetanus
Toxoid (TT) immunization, and HIV-testing were performed for more
than 90% of attendants (Table 3). Abdominal examinations as well as
blood tests were performed less frequently, and the numbers differed
between the facilities. About 50% of women received health education.
About 25% experienced discomfort due to many students or waiting for
more than one hour. Overall satisfaction with the service was high
(31% very satisfied and 59% acceptable), but 10% reported being not
satisfied.
Table 2: ANC utilization patterns for 1132 women who had given birth
within the previous 12 months in the Jimma area1.
ANC facility

Jimma Hospital

31.9 (359)

Higher 2 Health Centre

13.0 (146)

Jimma Town Health Centre

19.1 (215)

Serbo Health Centre

4.9 (55)

Agaro Health Centre

22.2 (250)

Others

8.9 (100)

Gestational age at 1st visit

1st trimester

31.3 (336)

2nd trimester

57.8 (621)

3rd trimester

10.9 (117)

Number of visits

3.1 (32)

7.6 (80)

19.7 (207)

25.2 (265)

5+

44.4 (466)

Table

3:

practices,

Reported
and

ANC

content

of

care,

surroundings

(%)

health
by

staff

facility

according to 1132 ANC attendants who had given birth

within the previous 12 months in the Jimma area1.

Physical examination
Blood pressure

98.

Weight measurement

0
98.

Abdominal examination

3
95.

Laboratory tests
HIV test

96.

Blood analyses2

9
80.

Urine analysis

6
93.
6

TT immunization

85.

Health education topics

Danger
signs
during

44.

pregnancy
Need for

1
62.

health

facility

delivery
HIV and PMTCT

1
61.

Nutritional

1
64.

needs

during

pregnancy
Breastfeeding

1
59.

ANC surroundings
Waiting more than

43.

hour

preservice
Poor cleanliness of institute
Practice of health professionals
Discomfort due to students

9
5.0

36.

Poor

8
6.7

conduct

of

health

professionals
Nutritional practice of women
Reduced food intake

37.

Iron supplementation
Overall

1
6.8

Lack of blood pressure testing, abdominal examination, HIV-testing,

and TT immunization was not associated with satisfaction (Table 4).
Women who did not have other laboratory tests than the HIV test were
more likely to report being not satisfied with ANC. Moreover, health
education, long wait time, poor cleanliness of the health facility, and

discomfort due to many students were related to the dissatisfaction.

Further,

poor

conduct

of

health

professionals

showed

strong

association with dissatisfaction.

Physical examination

satisfied

not satisfied

Not associated
with
satisfaction

No blood pressure
measurement
No weight
measurement
No abdominal
examination
Laboratory tests
No HIV test
No blood analysis,
other
No urine analysis
No TT immunization
No health education
on need of health
institution delivery
Waiting more than 1
hour
Poor cleanliness of
health institution
Discomfort due to
students

Poor conduct of health

staff

3.2. Qualitative Findings

Participants in in-depth interviews were women aged 18 to 32 years,
most of whom were primiparous, but also women with three and four
children

were

interviewed.

They

were

housewives,

students,

employees, and day labourers. Nine attended ANC service; two did not
attend at all; and another two had contact with the service but did not
classify themselves as attendants: one because she never reached the
awareness that ANC is a special program for follow-up care for
pregnant women.
A central aspect shared by both women and men was that women
were considered vulnerable while pregnant and hence needed to be
taken care of by their husbands and relatives. For some women,
pregnancy added to the worry associated with poor living conditions
and concerns about how to take care of their family. In general, women
and men made joint decisions about health practices during pregnancy.
Relatives, especially the mothers of the pregnant women, also played a
significant supervising role during pregnancy. Seeking health care was
seen as a way to cope with the increased vulnerability of being
pregnant. Overall, the women described ANC in positive terms.
3.2.1. Lack of Guidelines and Continuity of ANC Resulted in Poor
Quality of Care

According to our enquiries and observations, there were no ANC

guidelines in Ethiopia. The only references to guidelines were a
Ministry of Health poster and a training manual for health professionals
found at health centres, both based on the FANC guidelines (with four
visits per pregnancy). The booking of ANC visits followed the FANC
guidelines

at

recommended

health

centres,

monthly

where,

appointments

in
until

contrast,
28

the

weeks,

hospital
biweekly

appointments until 36 weeks, and then weekly appointments until the

birth.
At all facilities, health professionals and consultation rooms were
dedicated to ANC provision. At some facilities, the ANC duty would shift
among all staff; at others, one person was responsible. At the health
centres, the permanent staff members providing ANC were all at the
nurse or midwife level; however, occasionally, the service would be
provided by students, alone or under supervision. At the hospital, the
ANC facility was staffed by nurses who did the measurement of blood
pressure and body weight, whereas all other physical examinations and
consultations were provided by medical students, who cycled through
the department every 14 days, which resulted in a lack of continuity of
care.

The

students

were

providing

service

with

reference

to

obstetricians, but the level of supervision was low, as the obstetricians

were busy attending a high number of complicated deliveries and other
teaching assignments. Further, at the hospital, collaboration problems
between nurses and medical students were frequent. The nurses and
midwives indicated that the medical students received more attention
and feedback from the senior medical staff than they did, and this
made them feel less appreciated. The nurses would not have authority

over medical students, so nurses refrained from taking responsibility in

the presence of medical students.
During observations we noted that there was a lack of alignment of
procedures in the facilities where the staff rotated or students were in
charge of the ANC service. This was visible in the registration
procedure, which changed from provider to provider, as well as in the
placement of the equipment. During visits to the clinics, it was difficult
to find a person who took the lead of providing the ANC services. In
contrast, at Serbo and Higher 2 Health Centres, one person was in
charge of ANC, and this created continuity and a sense of leadership.
At all facilities, a standard registration book had a fixed place. Though
always present, the registration procedures were faulty with no basis
for reflection or adjustment of procedures. It was observed that
supervision of the ANC staff and practice was minimal, which seemed
to lead to apathy in the service provision. The observed lack of
continuity, thorough registration procedures, and supervision were not
reported a concern by the health staff during the workshops. However,
they did note that preventive services were not prioritized as much as
curative services. The interviews with the senior health staff indicated
that these issues were part of the clinical culture and that solving them
was not a priority.
At the workshops, the health professionals themselves requested
training on FANC, especially in-service training that could improve their
skills during their normal working hours. They felt that it was
challenging to provide good-quality service due to the lack of
equipment and the low standards of the physical environment.
3.2.2. Lack of Laboratory Facilities and Supplies Caused Frustration

Serbo, Higher 2, and Agaro Health Centres only had laboratory facilities
for HIV-testing and not for analysis of urine, haemoglobin, and syphilis
and determination of blood group. Therefore, the staff referred ANC
attendants to private clinics, where testing could be done based on
user fees. At the hospital and Jimma Town Health Centre, the
laboratory facilities were available, but, at the health centre, a
minimum fee was charged: haemoglobin 3 ETB (0.17 USD), syphilis 3
ETB, blood group and Rh status 4 ETB (0.23 USD), and urine analysis 3
ETB. Iron and folic acid supplementation was not given for free at any
site.
Women expected ANC service to be free, and therefore the costs of
laboratory

tests

caused

frustration.

For

some,

tests

were

too

expensive, and they gave up taking tests. This affected their

satisfaction with the health centres: Unlike the hospital, the health
centres are short of laboratory equipment and chemicals. If it is well
equipped like the hospital it will be acceptable (female participant). A
woman, at her first ANC visit, was asked to take laboratory tests at a
private clinic with user fees. At the second ANC visit, she was asked to
take more tests at the private clinic and was refused TT immunization
before she had the laboratory results. She did not have money for
more laboratory services and refrained from further check-ups.
3.2.3. High Priority of HIV Services Is a Contrast to the Priority of ANC
The women associated pregnancy and the need for health care with
HIV, but with no other specific diseases. The health system in Jimma
had previously received funding for HIV/AIDS activities, for example,
training of staff. Our observations revealed that the staff members
were more careful to provide good-quality service and to make

thorough registrations for the PMTCT service than they were for the
basic ANC service. The increased attention might be due to close
follow-up and guidance by senior doctors, health authorities, and donor
agencies.
3.2.4. Poor Communication and Interaction between User and Provider
Resulted in Broken Trust
Some women mentioned that HIV-counselling was provided, whereas
the

majority

said

that

no

health

education

was

given.

This

inconsistency was supported by our observations, and the staff

expressed a wish to improve the health education. The interactions
between users and providers were dominated by the provider, and
conversations were often formal and very limited. This seemed to be
what both parts expected. Further, the women indicated that the
service sometimes occurred without the expected content of ANC and
that the staff sometimes delayed services, even though they were not
busy. Poor conduct of health professionals was a recurring theme
mentioned in the interviews. Both women and men reported that some
health professionals had a reputation of purposely insulting the
women.
A particularly important issue for the women and their partners was
that ANC was not conducted in privacy, due to the presence of a high
number of students. We observed that it was common to have five
health providers in the room conducting ANC services for one woman.
A woman put it this way: There was not enough privacy. Many doctors
including students accompanied you. Any one up to 10 persons
watched you. At that moment, it is horrible, when you exhibit an
undressed body. There was no time where I was examined in privacy.

This lack of privacy made women feel embarrassed, and several

refrained from further ANC visits.
Some

of

the

students

were

inexperienced

and

inadequately

supervised. The women sometimes felt unsafe in their hands: I was

not examined by trained health providers. Then I developed fear. It was
students who gave the services. There was a woman who supervised
the students. It is based on her advice that they gave you help. Since
they pushed down my abdomen without care, I did not build any
confidence in them (female participant).
In adjacent rooms, to which the doors could not close, other services
were provided. A father recommended that if many health providers
had to be present, the supervision and discipline should be improved:
If nobody enters the room during examination, it is better. If
somebody enters the room during examination the mother might feel
shy and will not answer the questions the woman will be forgotten on
the examination couch and the staff will start to discuss with each
other. So, the door should be closed during examination.
Poor conduct of staff was identified as a problem by the staff
themselves, but they did not reflect on the issues of lack of privacy and
the negative effect on the well-being of their clients.

4. Discussion
4.1. Main Findings
The need for ANC strengthening was assessed using a mixed-method
approach. There were no national guidelines for ANC in Ethiopia, and
the providers in Jimma did not have support to give high priority to
ANC. Within the health system, teaching of health professional

students was given high priority, and that contributed to a lack of

continuity and privacy for women. Poor user-provider interaction was a
serious concern for the women, and contributed to a lack of trust in the
providers. The interaction was deemed poor because of a combination
of a poor privacy culture, a high number of students present, and a
lack of dialogue and attention to the womens individual needs.
Therefore, we conclude that the women and the health system have
different priorities, and, from the womens point of view, the agenda of
the health system compromises the care provided, and that hinders
trust and mutual respect. Further, the care provision was compromised
by inadequacies in leadership, supervision, skills of professionals, and
routine registrations as well as a shortage of laboratory facilities.
However, in the PMTCT services integrated in the ANC program, priority
and funding made it possible to overcome these issues.
4.2. Satisfaction with Care
The measurement of satisfaction with care in the survey was relevant
as an overall assessment of the womens evaluations of the care
received; however, satisfaction has previously been shown to be
dependent on the expectations towards care [30, 31], and, for
example, primigravidas might have difficulties knowing what to expect
from ANC. In this study, a relatively small proportion of women
reported being not satisfied with ANC, and this might be due to
underreporting

dissatisfaction,

as

respondents

tend

to

report

favourably on questions of perceived quality of care or satisfaction

[32]. By triangulating the findings of the qualitative data against those
of the qualitative study, we found that the analysis of the predictors of
dissatisfaction offers some guidance towards what women do not want
from care. The qualitative results give a deeper understanding of why

laboratory tests, privacy issues, and conduct of health staff had strong
statistical association with satisfaction. Lack of health education was
also significantly associated with dissatisfaction but was not a strong
theme in the qualitative interviews. However, limited verbal interaction
between provider and user was, and it is, interpreted as a barrier for
counselling during ANC. Limited verbal interaction between user and
provider has been described in other sub-Saharan settings [33, 34],
and it has been ascribed in part to the fact that existing social
hierarchies in the surrounding society are reflected inside the facility;
poor and less-educated patients are often treated less politely and are
given less attention than middle-class or wealthy patients [35, 36].
4.3. The Importance of User Perceptions of ANC for Place of Delivery
In this study, 67% of the women gave birth in a health facility, which is
higher than the national urban average (51%), but still lower than the
ANC coverage (83%). Some studies show that the use of ANC predicts
the use of health institution delivery [37], whereas others do not [7,
38]. Provider attitudes have been described as barriers for use of
health institution delivery [34, 39]. We hypothesize that increased
attention to what women want from ANC could increase both the
number of follow-up visits during pregnancy and the number of health
facility

deliveries.

This

proposition

is

supported

by

recent

multicountry study which found that the relation between the use of
ANC and the place of delivery in previous studies has been
underestimated and that governments and NGOs should place more
importance on the role of ANC in efforts to promote skilled birth
attendance [13]. Further, it could be speculated that the ability of the
health professionals to improve the health of the pregnant women

might increase, if the women are involved as more active partners in

discussing their health status and in the screening for health problems.
4.4. Focus on HIV
This study revealed that both the health system and the women had
high awareness of HIV, which may reflect how a vertical program can
be well implemented in a less functional horizontal program. Both the
high priority of HIV and the general health system falling behind have
been described in other settings [40, 41]. Today the efforts to improve
public health in low-income countries are partly funded by global
health initiatives, and these activities lead to new inequalities in health
care provision unless better integrated in the overall health system
[42]. We believe that the success of the implementation of PMTCT
services should be considered a model for how health system
strengthening can be accomplished for improved maternal health.
4.5. From Policy to Practice
Although the importance of ANC for maternal health is under debate,
the guidelines for FANC are based on best available evidence, ANC is
implemented globally, and coverage is high. Therefore, it is surprising
how poorly the FANC guidelines are implemented in low-income
countries, including Ethiopia. Langley and Denis [43] suggest that
quality improvement initiatives in general seem to neglect that
innovations (although scientifically sound) imply a distribution of costs
and benefits to several groups of stakeholders who have more or less
interest in and power to support changes. Further, they argue that
different stakeholders hold different values about what is good and
right, and that power relations in health care systems are diffused
because of the need for both professional and managerial expertise. In

the present study, it was clear that quality assurance of ANC/FANC was
not a shared interest; an example is that for the medical students it
might be beneficial to keep the traditional model for booking of ANC
visits (with many visits per woman) as they would gain more
experience. They might have had relatively good chances for
upholding this practice, as they seemed to be close collaborators of the
senior medical doctors. Further, the collaborative challenges seen
between the nurses, medical students, and senior doctors might reflect
differences in values about what good care is. Clearly, the differences
in the priorities of the women and the health system are an example of
differences in what good care is considered to be. Finally, the diffuse
leadership of ANC and hence the lack of supervision and guidelines
were noted, and those were obviously due to the low priority and
funding of ANC. Thus, if dedicated implementation of FANC was a goal
in Ethiopia, it is clear that in the implementation process the
micropolitics of power, interests, and values would be important to
address.
4.6. Study Strengths and Limitations
The survey is based on a relatively large study population, with a very
high

participation

rate.

We

cannot

preclude

selection

bias;

socioeconomically disadvantaged women, women with stillbirths, and

mothers who experienced infant deaths might be underrepresented.
Nevertheless, we did everything feasible to ensure inclusion of all
women: local female data collectors were trained and kebele guides
assisted in identifying the women. The kebele guides facilitated the
acceptance of the survey in the community.

The qualitative interviews with women were conducted in their own

homes because it was assumed that they would be more comfortable
there. This was an important step to reduce the effects it could have
when relatively powerful people from the local community together
with a foreigner ask questions about the health system. In general, the
participants appeared happy to meet us and to reflect on the theme
introduced. At the workshops with the health professionals, it was
known by all that this study was part of a needs assessment for a
future intervention. Therefore, the health staff had reasons to be
strategic in their expressions. Further, the health centre leaders were
present,

and

it

might

have

been

difficult

to

express

critical

perspectives on the local leadership, including perspectives on

supervision, continuity, and job responsibilities, and this is one
limitation that could possibly have influenced our data. However, the
extensive field stay (SFV) and the participation of local researchers
(DN, AGM, and AT) in this study alleviated this risk of bias and provided
a strong background for developing interview guides and for the
contextualisation and interpretation of the data [44].
The findings were relatively consistent, and this consistency enhanced
the validity and relevance of our conclusions [45].
4.7. Relevance of the Findings for Other Contexts
Data in this study stem from a single area in Ethiopia, and a discussion
of transferability is relevant [45, 46]. In Jimma, the coverage of
laboratory testing during ANC was higher than the national coverage;
thus, the issue of poor-quality laboratory facilities seems national. From
other low-income countries, it is reported that the quality of ANC is
compromised by shortages of laboratory reagents and drugs, low

coverage of health education, and low compliance with the FANC

guidelines and also that service varies between facilities and countries
[912, 41, 4750]. In the present study, we found the same challenges
and thus conclude that they seem to apply generally.
The focus of this study was the ANC system. However, the quality of
this program depends on the health system it is nested in. On a large
scale, funding and leadership are found to be cornerstones for health
system strengthening in low-income countries [51], and therefore it is
likely that the themes raised in this study are of particular interest for
Ethiopia, but also of general interest for health system strengthening in
low-income settings.
4.8. Implications for Practice
It seems essential that ANC services should be given increased
attention and that stronger leadership should be implemented with
more supervision and monitoring of the service providers. Based on
our findings, one suggestion for improved continuity of care could be to
avoid job rotations. Further, if many health professional students have
to be present during service provision, a different culture for how to
approach the women could be encouraged. In other settings, it has
been suggested that improved quality of care can be achieved by inservice training and improved supportive structures at managing levels
[10, 41, 47, 52].
Based on this needs assessment, an ANC strengthening intervention
(the Maternity Study) is to be developed. According to the MRC
guidelines

for

complex

interventions,

the

intervention

will

be

considered an exploratory trial, where the feasibility of implementing

the intervention and its acceptability to providers and users will be

tested [22]. The focus of the intervention should be on adaption and

implementation of ANC guidelines, availability of laboratory facilities
and supply, development and implementation of health education
materials, in-service training of health professionals in ANC services,
guidelines for ensuring privacy during consultations, and regular and
supportive supervisions of ANC professionals.

5. Conclusions and Perspectives

The ANC program in the study area was not based on guidelines. The
ANC coverage was high. Improvements are needed on guidelines
development and implementation, upgrading of laboratory facilities,
health education, and user-provider interaction as well as training of
health professionals.
National and international decision makers need to be aware of the
consequences of having one of the most utilized health care services
running without guidelines and structured supervision, for example,
inadequate quality of care and the loss of health professionals
motivation and users trust in the health care system. More importance
on the role of ANC in efforts to promote skilled birth attendance and
maternal health is needed. However, it is clear that dedicated
implementation of FANC takes strong leadership and we suggest
supportive supervision of health care providers geared towards
building trust and mutual respect to protect maternal and infant
health.

Conflict of Interests
The authors declare that they have no conflict of interests.

Authors Contribution
Sarah Fredsted Villadsen, Vibeke Rasch, and Henrik Friis conceived and
designed this study. Sarah Fredsted Villadsen, Dereje Negussie, Abebe
GebreMariam, and Abebech Tilahun conducted the study. Qualitative
analysis and write-up of qualitative sections were done by Sarah
Fredsted

Villadsen

and

Britt

Pinkowski

Tersbl.

Sarah

Fredsted

Villadsen, Vibeke Rasch, and Henrik Friis did the quantitative analyses.
All authors have contributed to the writing and approval of the final
version of the paper.

Acknowledgments
This study is a part of the JUCAN Project (Jimma University/University of
Copenhagen Alliance in Nutrition). The authors want to thank the
JUCAN team for their support and logistical assistance. They thank all
of the local stakeholders for their willingness to contribute. They thank
the

Jimma

University

Research

and

Publication

Office

for

the

permission to undertake the study. This study was supported by

Danida,

through

the

Consultative

Research

Committee

for

Development Research, and by the Danish Council for Independent

Research, Medical Sciences, the Danish Society of Obstetrics and
Gynaecology, and the Danish Research Network for International
Health Enreca Health. The funding bodies had no role in the study
design, data collection, data analysis, interpretation, or decision to
publish the findings.

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